Chain of command
Formal Definition
The hierarchical escalation pathway for clinical decision-making, communication, and conflict resolution — typically medical student → intern (PGY-1) → senior resident (PGY-2/3) → fellow → attending → department chair → hospital administration; designed to ensure decisions are made at the appropriate level of expertise while maintaining accountability and providing educational oversight.
How It's Used on the Ward
"Going up the chain" or "skipping levels" — when a clinical situation isn't resolving at the current level, escalating to the next person in the hierarchy; medical students skip to the intern first, interns skip to the senior resident, etc.; going too high without checking the immediate level can irritate the chain.
Example
""Nurse pages the medical student directly about a deteriorating patient at 2am. Student should not act independently and should not page the attending — the correct escalation is to call the intern on call first, then the senior resident, then the attending if needed, while staying with the patient and monitoring vitals.""
Clinical Context
Why it matters: (1) Education — interns and residents need graded responsibility to learn; bypassing them deprives them of learning opportunities and decision-making practice. (2) Information fidelity — the immediate supervisor knows the patient context intimately; pages to attendings lose important intermediate context. (3) Team cohesion — bypassing peers creates resentment and undermines trust. (4) Patient safety — the multiple levels provide redundancy and check. When to escalate: clinical urgency that cannot wait for the next level (e.g., patient is dying and the intern is unreachable — go up the chain until you reach someone), conflict resolution between team members (typically requires attending involvement for major decisions like disposition or goals of care). Students who inappropriately escalate to attending without intern/resident awareness create workflow friction. The hierarchy is bidirectional — attendings giving feedback through the team, not just to the student.